Counseling Form - CURE Childhood Cancer

First Name*

Last Name*

Email Address*

Phone*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Full Name of Child Diagnosed with Cancer/LCH/HLH/Aplastic Anemia*

Date of Birth*

Diagnosis / Type of Cancer*

Date of Diagnosis*

My child is:*

On Active Treatment
Has Completed Treatment
Deceased

Date of Death

Name of family member for whom you are seeking therapy. (Push + to add family members)

First Name	Last Name	Date of Birth (mm/dd/yyyy)	Relationship to patient	Ethnicity

How did you hear about CURE’s counseling Program?

By submitting this form, I give CURE Childhood Cancer permission to provide my name, contact information, and limited health information regarding the child with cancer to the Providers providing counseling services. By submitting I am also stating that I have read and understand these Guidelines and the Disclaimer provided above.*

I Consent (Please check box giving consent)

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Name

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